- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.10 / $210.10 / $210.10
| Facility | | $210.10 | $210.10 | $210.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.38 / $210.10 / $210.10
| Professional | | $192.38 | $210.10 | $210.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.80 / $263.56 / $565.98
| Professional | | $241.80 | $263.56 | $565.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.16 / $1,890.78 / $1,892.25
| Facility | | $1,052.16 | $1,890.78 | $1,892.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.02 / $223.68 / $1,070.69
| Professional | | $191.02 | $223.68 | $1,070.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.83 / $506.73 / $506.73
| Professional | | $226.83 | $506.73 | $506.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.90 / $335.21 / $758.02
| Professional | | $167.90 | $335.21 | $758.02 |